{"paper_id":"359981c0-a32a-4d84-967c-4929da759736","body_text":"1 Effect of nutrition assessment, counselling and support \n2 integration on mother- infant nutritional status, practices \n3 and health in Tororo and Butaleja districts, Uganda: A \n4 comparative non equivalent quasi experimental study\n5\n6 Samalie Namukose1,  Gakenia Wamuyu Maina2, Suzanne N Kiwanuka1 Fredrick Edward Makumbi3\n7\n8 1 Department of Health Policy Planning and Management, School of Public Health, College \n9 of Health Sciences, Makerere University, Kampala Uganda\n10  2 Department of Community Health and Behavioural Sciences, School of Public Health, \n11 College of Health Sciences, Makerere University, Kampala Uganda\n12 3 Department of Epidemiology and Biostatistics, School of Public Health, College of Health \n13 Sciences, Makerere University, Kampala Uganda\n14 * snamukoseb@gmail.com\n15\n16 Abstract \n17 Background: Malnutrition remains a health challenge for women aged 15 to 49 years and their \n18 infants. While Nutrition Assessment Counselling and Support (NACS) is considered a \n19 promising strategy, evidence on its effectiveness remains scanty. This study assessed the effect \n20 of comprehensive NACS package on the mother-infant practices, health and nutrition outcomes \n21 in two districts in Eastern Uganda. \n22 Methods: A comparative non equivalent quasi experimental design was employed with two \n23 groups; Comprehensive NACS (Tororo) and Routine NACS (Butaleja).  Pregnant mothers \n24 were enrolled spanning various trimesters and followed through the antenatal periods and post- \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n25 delivery for health and nutrition status. Infants were followed for feeding practices, health and \n26 nutritional status at birth and weeks 6, 10, 14 and at month 6, 9 and 12 post-delivery. \n27 Propensity score matching ensured study group comparability. The NACS effect was estimated \n28 by nearest neighbour matching and the logistic regression methods.  Statistical analysis utilised \n29 STATA version 15 and R version 4.1.1. \n30 Results: A total of 666/784 (85%) with complete data and were analysed (routine: 412, \n31 comprehensive: 254). Both groups were comparable by mothers’ age, MUAC, prior antenatal \n32 visits, meal frequency, micronutrient supplementation and instances of maternal headache, \n33 depression and diarrhoea. However, differences existed in gestation age, income, family size, \n34 education and other living conditions.\n35 Comprehensive NACS infants exhibited higher infant birth weights, weight- for- age z-scores \n36 at the 3 rd -6 th visits (p<0.001), length- for- age z scores at the 4 th -7 th visits (p<0.001) and \n37 weight-for-length z-scores at the 3rd - 5th (p<=0.001) visits. Despite fewer episodes of diarrhoea \n38 and fever, upper respiration infections were higher.\n39 Conclusion: The comprehensive NACS demonstrated improved mother-infant nutritional and \n40 other health outcomes suggesting the need for integrated and holistic care for better maternal, \n41 infant and child health. \n42 Keywords: Effect, nutrition assessment counselling and support, practices, health and nutrition \n43 outcomes, mothers, infants.\n44\n45\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n46 Introduction \n47\n48 Maternal and infant malnutrition is a significant global health concern with significant \n49 implications on the overall health and well-being of both the mothers and their infants. The \n50 Global Nutrition report of 2022 [1]  indicated that 29.9% of women of reproductive age suffer \n51 from anaemia while 9.1% of all women were underweight. The prevalence of low birth weights \n52 was 14.6% among the newborns while 22%, 6.7% and 5.7% of children under 5 years were \n53 stunted, wasted and overweight respectively. In the same report, Sub-saharan Africa was noted \n54 to contribute to the highest burden of malnutrition with 32.6% of children under 5year stunted, \n55 5.2% wasted and 4% overweight while anaemia among the women of reproductive age was \n56 31.9%. According to the Uganda Demographic Health Survey (UDHS) of 2016 [2], the \n57 prevalence of stunting among children under 5 years was 29% while underweight and wasting \n58 was 11% and 4% respectively. Additionally, aneamia affects 32% of the women of \n59 reproductive age. These surveys and reports indicate the persistent challenge of malnutrition \n60 among the women of reproductive health and children calling for urgent need for intervention \n61 and improvement.\n62 Maternal nutrition is vital for the health and well being of both the mother and her developing \n63 infant. Maternal interventions aimed at improving nutrition practices before pregnancy, during \n64 pregnancy and lactation have been extensively studied for their potential to enhance maternal \n65 and infant health down the line [3–7]. Well nourished and healthy mothers are more likely to \n66 give birth to health babies, experience a healthy pregnancy and are less likely to experience \n67 life-threatening complications during pregnancy [8,9].\n68\n69 Several studies have demonstrated the positive impact of maternal interventions on the \n70 nutrition practices and growth of infants particularly when implemented in a multi-sectoral \n71 approach. For instance, implementation of a comprehensive range of interventions such as; \n72 breastfeeding promotion, education and counselling, maternal mental health, women \n73 empowerment, family planning, water, hygiene and sanitation, agricultural interventions has \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n74 shown promising results in reducing stunting rates [10]. Notable studies by Olutayo et al [11], \n75 Nadia et al [12], Bhutta et al [13] emphasize the importance of these holistic interventions in \n76 reducing stunting. However, it is important to consider the perspective put forth by  \n77 USAID/Advancing Nutrition [14] which argues against using stunting as a primary indicator \n78 of success of short term or single interventions at individual. Instead, stunting should be \n79 interpreted as a reflection of the population’s well-being. This view suggests a more \n80 comprehensive assessment of interventions success focusing of multiple short and long term \n81 causal factors to malnutrition instead of looking at the immediate outcomes.\n82 Additionally, numerous studies have shown that Nutrition Counselling and education during \n83 pregnancy significantly improve maternal-infant nutrition practices as well as the overall health \n84 and nutritional status of both mothers and infants. Dearden et al [15] demonstrated a positive \n85 effect of nutrition counselling and education on maternal meal frequency and diet \n86 diversification. These findings align with a  quasi- experimental study conducted by Kaleem et \n87 al [16] which indicated that Antenatal Counselling  improved the maternal dietary practices \n88 and nutritional status. Similarly, a study by Perez-Escamilla et al [17]   revealed a positive \n89 effect of maternal counselling on maternal and infant health and nutrition outcomes including \n90 birth weights and prevention of pre-term births. In contrast, Ghosh-Jereth et al [18] found that \n91 the maternal dietary intake remained low and anaemia rates were high despite targeted \n92 antenatal care including counselling at every visit. The authors attributed this lack of \n93 improvement to the poor quality of counselling, a finding also echoed by Nsiah-Asamoah et al \n94 [19] in their study on nutrition counselling interactions between the health workers and \n95 caregivers. While some studies showed positive effect of maternal nutrition counselling on the \n96 maternal-infant health and nutrition outcomes, contrasting findings indicate that the quality of \n97 the counselling and how it is delivered can have negative impact on these outcomes. More \n98 research is needed to bridge this gap and provide a clearer understanding on the effect of \n99 delivery of a comprehensive package including counselling on the mother-infant health and \n100 nutrition outcomes. \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n101 Therefore, providing high-quality health services, including preventive health services, \n102 antenatal, maternity and postnatal services as well as early diagnosis and treatment of medical \n103 conditions such as anaemia is crucial for improving women’s health. The World Health \n104 Organisation (WHO) and the Ministry of Health, Uganda recommends a comprehensive \n105 package of nutrition interventions to pregnant women for a positive outcome, including \n106 counselling on healthy eating and physical activity, guidance on infant and young child feeding, \n107 nutrition education on energy and protein intake, and daily iron and folic acid supplements. \n108 The package also includes energy and protein dietary supplements and high-protein \n109 supplements for the undernourished populations [20,21].\n110 Even before the release of the WHO guidelines in 2020, the Ministry of Health in Uganda had \n111 been implementing NACS initiative, aiming to integrate nutrition into the health system and \n112 consequently improving the health and nutrition practices and outcomes of the beneficiaries. \n113 The NACS intervention package was tailored to the specific nutrition needs of the clients and \n114 was in line with WHO’s recommendations on maternal nutrition care. Support was provided \n115 to mothers and their children, covering aspects such as optimal maternal nutrition, diversified \n116 diets, iron/folic acid supplementation, iodated salt consumption, deworming, malaria \n117 prevention, and provision of antenatal care package and encouragement to attend all the 8 \n118 visits. Breastfeeding education emphasized early initiation, exclusive breastfeeding for 6 \n119 months, and extended breastfeeding. Mothers of older infants received guidance on \n120 complementary feeding practices. Caregivers of sick children were advised on continued \n121 breastfeeding. The community system offered ongoing health and nutrition care, including \n122 livelihood and economic support to improve the health and nutrition outcomes. The \n123 malnourished mothers received therapeutic foods [22].\n124 While existing literature has assessed the impact of vertical maternal interventions on the health \n125 and nutritional status of mothers and infants, there is limited body of research on the effect of \n126 broad integrated interventions, such as NACS on the health and nutrition outcomes of \n127 beneficiaries. This study therefore, sought to assess the effect of comprehensive NACS \n128 package on the health and nutrition practices and status of mothers and their infants in Tororo \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n129 and Butaleja districts in Eastern Uganda. We tested the hypotheses that there was no difference \n130 in the maternal-infant health, nutrition practices and outcomes between the facilities which \n131 integrated comprehensive NACS, verses those with routine NACS. The findings of this study \n132 contribute to the growing body of evidence on the effectiveness of broad integrated \n133 interventions on the health and nutrition outcomes of the beneficiaries and provide insights and \n134 recommendations for scaling up the NACS approach.\n135 Pathways on the effect of NACS integration in the health system on maternal and infant \n136 health, nutrition practices, and outcomes \n137 Integration of comprehensive NACS into the health system will result into an integrated \n138 nutrition service delivery system which aims to foster a productive interaction between the \n139 service providers and mothers. Based on the health belief model, service providers were \n140 expected be motivated to impart knowledge and skills to mothers, enabling them take charge \n141 of their own health and nutrition. Based on the health belief model, these empowered mothers \n142 would then embrace optimal nutrition practices resulting in enhanced health and nutrition well-\n143 being. Consequently, this positive change would improve the health and nutrition outcomes of \n144 their infants, as illustrated in S1 Fig\n145 Insert S1 Fig\n146\n147 Material and Methods\n148 Study Design\n149 The study used a comparative non-equivalent quasi-experimental design with two groups; \n150 comprehensive NACS integration compared to routine NACS integration. \n151\n152 Study Setting and population\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n153 The study involved pregnant and lactating mothers, along with their respective infants. The \n154 two hospitals selected for the study were Tororo Hospital as the comprehensive NACS and \n155 Busolwe Hospital as the routine NACS.  The hospitals were similar by level of facility, \n156 ownership, funding, staffing norms, services provided and client load. Pregnant mothers in \n157 various trimesters were enrolled and their health and nutrition status monitored at the antenatal \n158 visits and post-delivery. Only women accessing antenatal care and residing in Tororo and \n159 Butaleja were included. During post-delivery, infants were monitored for their feeding \n160 practices, health and nutrition status till 12 months. \n161 Mothers and infants were followed through the scheduled visits at their respective health \n162 service points, which included, antenatal, labour suite/maternity, postnatal, children wards, \n163 young child and ART clinics. \n164\n165 Comprehensive NACS versus routine service delivery\n166 The comprehensive NACS package targeted both the health workers and mothers with their \n167 infants. The support to the health workers included: five-day training in NACS and Health \n168 Management Information System (HMIS) for nutrition in-service courses for staff at key health \n169 contact points, such as antenatal clinics, maternity, postnatal clinics, young child and HIV \n170 clinics; provision of anthropometric equipment, policy guidelines, job aides, information, \n171 education and communication materials for mothers; mentorships/support supervision of \n172 health staff to ensure quality service delivery; monitoring and reporting of nutrition \n173 interventions; employing quality improvement support to address gaps in NACS \n174 implementation; linking study subjects to community support structures for continuous \n175 nutrition care and support; and collaborating with key stakeholders and the district health \n176 management team to establish supervisory and support mechanisms for the intervention.\n177 To the mothers and their infants, the package included: nutrition assessment and categorization \n178 of the nutritional status; health and nutrition education on a diversified diet, recommended \n179 antenatal clinic visits, iron/folic acid supplementation, water hygiene, and sanitation; maternal-\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n180 infant nutrition counselling; provision of therapeutic feeds to identified malnourished cases; \n181 active follow-up of mother-baby pairs to ensure they receive the necessary nutrition services.\n182\n183 Routine service delivery\n184 In the routine NACS setting, some elements of NACS were integrated into the regular health \n185 care services provided such as growth monitoring and promotion for children, iron/folic acid \n186 supplementation. To ensure comparability, staff at both study settings were trained in NACS \n187 and HMIS for nutrition. They were provided with information, education and communication \n188 materials to enhance their capacity in nutrition education and counselling. Subsequently, the \n189 staff carried on with their services as per usual. The nutrition counselling placed a strong \n190 emphasis on promoting the consumption of  locally available foods for the management of \n191 malnutrition. [23]\n192 We determined the level of exposure to comprehensive verses routine NACS by closely \n193 supervising the data collection process and enhancing documentation of both the services \n194 rendered and the frequency with which the respondents accessed these services. \n195 Sampling\n196 The study employed purposive sampling approach, enrolling subjects who had given their \n197 consent on a continuous basis until the desired sample size was attained. In both study settings, \n198 the antenatal care clinic served as the entry point and the ANC register as the sampling frame. \n199 The enrolment of the study participants took 8 months from starting from 23rd October 2018 to \n200 25th May, 2019. The mothers were followed up till they gave birth, and the mother-infant pairs \n201 followed up for 12 months. Data was collected from 23rd October, 2018 to 25th July 2021. \n202\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n203\n204 Sample size calculation\n205 The sample size was calculated using the formular by V. Kasiulevicius et al [24] based on \n206 infant underweight as an outcome variable. \n207             n =\n[zα (1+ 1\nm) p(1― p) + zβ\npo(1―p0)\nm + p1(1―p1)\n]2\n(p0 ― p1)2\n208                                                        Where   p =\np1 + mp0\nm + 1\n209 Where,\n210 P0 was the probability of underweight infants in the control group – 0.113. \n211 P1was the probability of underweight infants in the intervention group – 0.07\n212 P0 was based on the Uganda Demographic Health Survey 2011 burden of malnutrition in the \n213 eastern region while P1 was an estimated reduction in underweight with the intervention.\n214 If α (alpha) = 0.05   then zα = 1.96\n215 If β (beta) = 0.80, then zβ = 0.845\n216 m was the number of control subjects per experimental subject = 2\n217 p = 0.0987\n218 n = 652 with the inclusion of 20% loss to follow up of mother-baby pairs. A sample size of 652 \n219 (217 in the intervention group and 435 in the control group) was estimated to detect a 4.3% \n220 reduction in the underweight infants at 80% power and 5% level of significance. \n221\n222 Data collection\n223 We pre-tested the data collection tools among the mothers and feedback was used to finalize \n224 the tools. The tool was designed in excel to facilitate the tracking of the mother- baby variables \n225 for their scheduled visits. \n226 Our research assistants underwent training on the data collection tools and data capture \n227 methods at a minimum of four points: recruitment/baseline, antenatal clinic visits, delivery and \n228 postnatal care clinic, and immunization scheduled visits. We encouraged mothers to deliver at \n229 the health facility where they were provided with a package of both routine and comprehensive \n230 package of services. To ensure data quality, we conducted regular supervision and spot checks. \n231\n232\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n233 At baseline/recruitment, we collected data on various aspects, including socio-economic and \n234 demographic characteristics, maternal health and nutrition practices, and maternal nutritional \n235 status. Throughout each antenatal visits, we monitored the mothers’ anthropometric data, \n236 health status and nutrition practices. Following delivery, we collected data on infant’s \n237 anthropometric measurement such as birth weight, length, head circumference as well as details \n238 about their feeding practices. Subsequently, we continued to track the infants’ anthropometric \n239 data, health and nutrition practices and status during the scheduled immunization visits.\n240 Anthropometric data and feeding practices for both the mother and her infant were collected \n241 using standard procedures. Mother’s weight was taken to the nearest 0.1gm using a digital \n242 Uniscale. The infant weight was measured to nearest 0.1 gm using the neonatal weighing scales \n243 at birth and thereafter a digital uniscale. Infant length was measured to nearest 0.1cm using an \n244 infantometer at birth and a height board for the subsequent visits. \n245 We measured the head circumference and Mid Upper Arm Circumference (MUAC) of infants \n246 using specialized tapes, with measurements recorded to the nearest 0.1cm. MUAC was \n247 measured for infants above 6 months and mothers. Additionally, we conducted health \n248 assessment for mothers, including evaluation for illnesses such as headaches, depression, \n249 diarrhea, fever and cough. For infants, we assessed episodes of diarrhea, fever and Upper \n250 Respiratory infections. \n251 In total, there were 15 scheduled appointments from the time of mother’s enrolment until the \n252 baby made 12 months of age. Mothers were encouraged to continue attending health facilities \n253 for continuous health care as well as participating in the informative health and nutrition \n254 education sessions. \n255\n256 Data management \n257 We used excel for data capture, STATA version 15 for data, cleaning and performing bivariate \n258 tests on all confounding background variables for both study settings. The variables included; \n259 weeks of gestation, age of the mothers, mothers’ education, marital status, mothers’ occupation, \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n260 mothers’ income, spouses’ income, spouses’ education level, previous ANC visits, distance to \n261 the health facility, type of transport used, total numbers of children, number of children alive, \n262 number of family members, number of children under 5 years, fuel for cooking, water source \n263 and faecal matter disposal. We cleaned data by synchronising the variable codes for the two \n264 data sets, checked for missing data, and excluded the variables with insignificant data.\n265 We characterised variables as continuous, binary, categorical and generated new variables. We \n266 checked the data set for normal distribution for the continuous variables. Descriptive analysis \n267 was conducted to compare mothers’ background characteristics in the 2 study arms. Continuous \n268 variables were compared using a 2 sample t-test while the categorical variables were compared \n269 using the chi square test.  \n270 Data analysis\n271 Because these groups were not randomly assigned and this being a quasi non- equivalent \n272 experimental study, we conducted propensity score matching to minimise potential imbalance \n273 and also create reasonable comparable groups, before assessment of the effectiveness of the \n274 NACS intervention. \n275 By creating more comparable intervention and control groups, propensity score matching can \n276 result into a more precise estimates of intervention effects and reducing confounders. On the \n277 other hand, matching reduces the sample size, because not all individuals may find suitable \n278 matches resulting in a loss of statistical power and precision [25–27].\n279 The propensity score matching process involved; defining the intervention (comprehensive \n280 NACS) verses control (routine NACS) groups, identification of the variables before \n281 administration of the intervention, estimating the propensity scores, checking the initial balance \n282 of the variables for both groups using mean differences, using the nearest-neighbor matching \n283 method  to pair individuals in intervention and control group based on their propensity scores, \n284 assessing the quality of the matches, and thereafter estimating the effect of comprehensive \n285 NACS on maternal-infant practices, health and nutritional status [27].\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n286 Using the R software version 4.1.1, we estimated the NACS effect on maternal-infant nutrition \n287 practices, health and nutritional status by comparing various methods such as nearest \n288 neighbour, null and full matching methods.  The nearest neighbour matching using the logistic \n289 regression propensity score model provided the best balance compared to other matching \n290 methods such as; full matching using a probit regression propensity score, nearest neighbour \n291 matching using a probit regression propensity score, null probit, full matching using a logistic \n292 regression propensity score as determined by the lower standardised mean difference statistics. \n293 The enrolment and data analysis flow chart is illustrated in S2 Fig.\n294 Insert S2 Fig\n295 Ethical approval\n296 This study was approved by: the Higher Degrees, Research, and Ethics Committee – \n297 Institutional Review Board at Makerere University School of Public Health (MaKSPH \n298 HDREC 24/01/2017), the Uganda National Council of Science and Technology (SS 4251), and \n299 the Office of the President in Uganda (ADM/194/212/01). An official letter from the Ministry \n300 of Health was written to the Tororo District Health Officer to seek for permission to conduct \n301 the study. The Principal Investigator informed both the District Health Officer and the District \n302 Resident Commissioner about the study plan before its execution. Participating mothers were \n303 asked to sign informed consent form. The mothers who were unable to read and write provided \n304 their informed consent using their thumbprint.\n305\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n306 Results\n307 A total of 784 mothers were enrolled in the study; 423 from the Routine NACS setting and 361 \n308 from the Comprehensive NACS setting. One hundred (118) mothers were excluded from the \n309 analysis due to missing data while 666 mothers were considered in the final analysis, majority \n310 from the routine (412) compared to comprehensive (254) NACS groups.  \n311 The mothers’ characteristics at enrollment were compared in the two study arms and the results \n312 are shown in the Tables 1 and 2. The findings indicated no significant difference between the \n313 mother’s age (p= 0.466), prior antenatal visits for this pregnancy (p=0.316), number of family \n314 members (p=0.007) between the two groups at enrollment. However, there was a significant \n315 difference in the weeks of gestation (p=0.023), mothers’ income (p=0.000), spouses’ income \n316 (p=0.000), number of children (p=0.000), number of children alive (p=0.000),  number of children \n317 < 5years (p=0.001), distance to health facility (p<0.001), mothers’ education (p<0.001), marital \n318 status (p<0.001), mothers’ occupation (p<0.001), spouses’ education (p<0.001), type of transport \n319 (p<0.001), cooking method (p<0.001), water source (p<0.001), and fecal matter disposal \n320 (p<0.001).\n321 Table 1. Mothers’ characteristics at enrolment in the routine verses comprehensive study arms for \n322 continuous variables\nVariable name\n(Comprehensive NACS=254, Routine NACS = 412)\nt-test p-value\nMothers’ age -0.730  0.466\nWeeks of gestation  2.277  0.023\nMothers’ income -4.682  0.000\nSpouse income -4.997  0.000\nPrio antennal visits for this pregnancy  1.003  0.316\nNumber of children 11.400  0.000\nNumber of children alive   5.725  0.000\nNumber of family members   2.669  0.007\nNumber of children less than 5 years   6.842  0.000\n323\n324\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n325 Table 2. Mothers’ characteristics at enrolment in the routine verses comprehensive NACS \n326 study arms for categorical variables before propensity score matching\n327\n328\nVariable name Routine NACS\nN=412\nComprehensive \nNACS\nN=254\nChi-square Test \n(p-Value)\nDistance to health facility\n<5 Km\n>5 km\n96.1%\n3.9%\n60.6%\n39.4% <0.001\nMothers Education \nNo Education\nPrimary\nSecondary\nHigher\n5.8%\n62.9%\n26.9%\n4.4%\n1.2%\n44.9%\n40.6%\n13.4%\n<0.001\nMarital Status \nMarried\nNot married\n94.4%\n5.6%\n99.6%\n0.4% <0.001\nMothers occupation \nFormal\nInformal\n6.8%\n93.2%\n18.1%\n81.9% <0.001\nSpouse’s education \nNo Education\nPrimary\nSecondary\nHigher\n4.2%\n49.3%\n38.7%\n7.8%\n1.2%\n25.6%\n55.1%\n18.1%\n<0.001\nType of transport\nMotorised\nWalking\n50.7%\n49.3%\n92.1%\n7.9% <0.001\nCooking method\nFirewood\nCharcoal\nGas\n79.9%\n19.9%\n0.2%\n52.8%\n46.1%\n1.2%\n<0.001\nWater source \nWell\nBorehole\nTap water\n0.2%\n96.8%\n2.9%\n16.1%\n44.1%\n39.8%\n<0.001\nFaecal matter Disposal\nLatrine\nToilet\n99.3%\n0.7%\n89.0%\n11.0% <0.001\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n329 Propensity score matching was used to create comparability between the study groups. The Null \n330 model was used to check the initial imbalance in the two groups that the matching methods \n331 eliminated step wise. Table 3 shows severe imbalances as reflected by the standard mean \n332 differences computed by the R software.  All values close to zero in the standard mean differences \n333 reflected better matches while those away from zero reflected severe imbalances. The variable \n334 ‘number of children’ had the highest difference (-4.7263) indicating severe imbalance while the \n335 variable ‘nutrition status by MUAC’ had the lowest difference (0.0019) indicating that mothers in \n336 the both groups had comparable nutritional status, which conclusions resonate with exiting \n337 literature [28].  \n338 Table 3: Propensity score matching null model for checking initial imbalance between the \n339 comprehensive and routine NACS study arms\nVariables  Means \nTreated\nMeans Control  Mean difference\nDistance                                                   0.8513          0.1053   3.1896     \nMother age \n15-24                                         \n25-49                                         \n 0.4762        \n 0.5238        \n \n 0.5140\n 0.4860\n-0.0758          \n 0.0758          \nMothers’ education\n1. No Education                              \n2. Primary                                   \n3. Secondary                                 \n4. Higher                                    \n \n0.0119        \n 0.4444        \n 0.4087        \n 0.1349        \n \n 0.0562\n 0.6433\n 0.2556\n 0.0449\n-0.4082          \n-0.4001          \n 0.3115          \n 0.2634          \nMarital status\n1. Married                                 \n2. Not Married                             \n \n0.9960        \n 0.0040        \n 0.9438\n 0.0562\n 0.8305          \n-0.8305          \nMothers’ occupation\n1. Formal                                     \n2. Informal                                   \n0.1825        \n0.8175        \n0.0674\n0.9326\n 0.2980          \n-0.2980          \nSpouse education\n1. No Education                              \n2. Primary                                   \n3. Secondary                                 \n4. Higher                                    \n \n0.0119        \n 0.2579        \n 0.5476        \n 0.1825        \n \n0.0365\n0.5056\n0.3820\n0.0758\n-0.2269          \n-0.5661          \n 0.3327          \n 0.2762          \nPrior ANC visits \n \n2.0397        2.1011 -0.0626     \nDistance to hospital\n1. Less than 5km                       \n2. ≥ 5km        \n \n0.6111        \n0.3889        \n0.9635 \n 0.0365\n-0.7228          \n 0.7228          \nType of transport\n1. Walking                                     \n2. Motorized                                   \n0.0794        \n0.9206        \n \n0.5028\n 0.4972\n-1.5665          \n 1.5665          \nNo. of children 1.0198         2.6236 -4.7263     \nNo. of children alive                                                1.5437         2.4129 -0.5786     \nNo of chn < 5years                                                  0.7540         1.2809 -0.6142     \nType of fuel used  \n1. Firewood                                         \n2. Charcoal                                         \n3. Gas                                              \n0.5278         \n0.4603        \n0.0119        \n \n 0.7978\n 0.2022\n 0.0000\n-0.5408          \n 0.5178          \n 0.1098          \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\nWater source\n1. Well                                      \n2. Borehole                                  \n3. Tap Water                                 \n \n0.1627        \n0.4405        \n0.3968         \n  0.0028 \n  0.9691\n  0.0281\n 0.4332          \n-1.0648          \n 0.7537          \nFaecal matter disposal\n1. Latrine                              \n2. Toilet                               \n0.8889         \n0.1111        \n \n  0.9916\n  0.0084\n-0.3267          \n 0.3267          \nMother wtg (kg) 1st visit                                               64.2496        60.7542  0.3124     \nNutritional status by MUAC\n1. Normal (Green)                               \n2. Malnourished (Yellow/Red)           \n 0.9722        \n 0.0278        \n \n 0.9719\n 0.0281\n 0.0019          \n 0.0019          \nNo. of meals                                                 3.0992         2.8792  0.2940     \nIron folic acid supplement\nNo                                     \n \n0.0238        \n \n 0.0028  0.1377          \nYes                                     0.9762         0.9972 -0.1377          \nHistory of headache\nNo                                           \nYes                                          \n \n1.0000        \n 0.0000        \n 0.8034\n 0.1966\n 0.6465          \n-0.6465          \nHistory of depression\nNo                                        \nYes                                       \n \n1.0000        \n0.0000        \n \n 0.9803\n 0.0197\n 0.1851          \n-0.1851          \nHistory of diarrhoea\nNo                                                    \nYes                                        \n1.0000        \n0.0000        \n 0.9888 \n 0.0112\n 0.1393          \n 0.1393          \nHistory of fever\nNo                                             \nYes                                            \n \n0.9960        \n 0.0040        \n \n0.9298\n0.0702 \n 1.0539\n-1.0539          \nHistory of cough\nNo                                             \nYes                                            \n \n1.0000        \n0.0000        \n \n0.9522\n0.0478\n 0.2927          \n-0.2927          \n340\n341 Effect NACS integration on the mothers-infant health, nutrition practices and \n342 status \n343 The study assessed the effect of NACS integration on maternal-infant nutrition practices as well \n344 as its effects on health and nutritional status. This assessment employed the nearest neighbour \n345 matching method along with a logistic regression propensity score model and the results are shown \n346 in Table 4.\n347             \n348\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n349           Table 4.  The effect of NACS integration on the mother-infant nutrition practices, health and \n350 nutrition status using nearest neighbour matching logistic regression propensity score model \n351\nVariable name Contrast\n 1-(Comp \nNACS)\n0-(Routine \nNACS)\nEstimate SE P value CI\nMother variables N=252 N=252\nMeal frequency at \n2nd visit\n1 0 0.008 0.070 0.911 -0.13, -0.146\nDiet Diversity Score\n2nd visit 1 0 -3.110 0.263 <0.001 -3.630, - 2.600\n3rd visit 1 0 -2.980 0.213 <0.001 -3.400, -2.560\n4th visit 1 0 -2.690 0.149 <0.001 2.990,   -2.400\nIron/ folic acid \nsupplementation\n2nd visit 1             0 -0.029 0.010 0.006 -0.049, -0.008\n3rd visit 1 0 -0.024 0.010 0.012 -0.043 , -0.005\n4th visit 1 0 -0.035 0.015 0.017 -0.064 , -0.006\nWeight at       \n2nd   visit 1 0 1.040 0.272 <0.001 0.507 -1.570\n3rd   visit 1 0 2.690 0.422 <0.001 1.860 – 3.520\n4th visit 1 0 5.860 1.990 0.003 1.950 – 9.760\nNut.status by (MUAC)\n2nd visit 1 0 0.038 0.018 0.032 0.003- 0.072\n3rd visit 1 0 0.026 0.009 0.047 0.008 -0.044\n4th visit 1 0 0.025 0.015 0.091 0.004- 0.054\nHistory of headache\n2nd   visit 1 0 0.020 0.009 0.020 0.003 - 0.037\n3rd visit 1 0 0.044 0.013 <0.001 0.020- 0.069\n4th visit 1 0 0.078 0.022 <0.001 0.034 - 0.121\nHistory of \ndepression\n2nd visit 1 0 0.013  0.007     0.070 -0.001, -0.026\n3rd Visit 1 0 0.008 0.005 0.160 -0.003, -0.018\nDiarrhoea at 3rd visit 1 0 0.018 0.008 0.030 0.002 -0.034\nHistory of fever       \n2nd visit 1 0 0.020 0.009 0.019 0.003 - 0.037\n3rd visit 1 0 0.049 0.014 <0.001 0.023 - 0.076\n4th visit 1 0 0.030 0.013 0.021 0.005 - 0.055\nInfant variables       \nInfant birth weight 1 0 0.191 0.100 0.056 -0.005, -0.387\nInfant weight at       \n3rd visit 1 0 1.050 0.111 <0.001 0.835 -   1.270\n4th Visit 1 0 1.130 0.106 <0.001 0.923 - 1.340\n5th visit 1 0 1.930 0.107 <0.001  1.720 -   2.140\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\nInfant head cirm \n3rd visit 1 0 3.900 0.248 <0.001  3.410 -  4.380\n4th visit 1 0 3.900 0.248 <0.001  3.410 - 4.380\n5th visit 1 0 0.020 0.009 0.019 0.003 -0.037\nWt for Age Z-scores \n3rd visit 1 0 1.800 0.233 <0.001 1.350-2.260\n4th visit 1 0 1.700 0.208 <0.001 1.290 -2.110\n5th visit 1 0 2.730 0.202 <0.001 2.330 – 3.130\n6th visit 1 0 0.265 0.159 0.096 -0.047, -0.577\nLength for Age Z-\nscores\n4th visit 1 0 0.634 0.246 0.010 0.151 – 1.120\n5th Visit 1 0 0.761 0.222 <0.001 0.326 – 1.200\n6th visit 1 0 3.990 0.281 <0.001 3.440 – 4.540\n7th visit 1 0 4.630 1.140 <0.001 2.470 – 6.780\nWt. for Length Z-\nscores at\n3rd visit 1 0 6.250 0.475 <0.001 5.320 – 7.180\n4th visit 1 0 1.460 0.356 <0.001 0.763 – 2.160\n5th visit 1 0 2.770 0.342 <0.001 2.100 – 3.440\nHistory of Upper \nRespiratory \nInfection\n5th Visit\n1 0 0.043 0.013 <0.001 0.018 - 0.069\n6th visit 1 0 0.155 0.023 <0.001 0.110 - 0.199\n7th visit 1 0 0.294 0.029 <0.001 0.237 - 0.350\n8th visit 1 0 0.315 0.029 <0.001 0.258 - 0.372\nHistory of infant \ndiarrhoea\n5th visit\n1 0 -0.168 0.080 0.036 -0.324, -0.011 \n6th visit 1 0 -0.146 0.080 0.067 -0.302- 0.010 \n7th visit 1 0 -0.033 0.049 0.506 -0.130- 0.064 \n8th visit 1 0 -0.126 0.067 0.061 -0.130- 0.064 \nHistory of infant \nfever\n1st visit\n1 0 -0.054 0.030 0.072 -0.113- 0.005 \n3rd visit 1 0 -0.005 0.012 0.694 -0.029- 0.019 \n4th visit 1 0 -0.409 0.086 <0.001 -0.576, -0.241 \n5th Visit 1 0 -0.111 0.076 0.145 -0.260- 0.038 \n6th visit 1 0 -0.023 0.062 0.712 -0.144 - 0.099 \n7th visit 1 0 0.028 0.050 0.569 -0.070 - 0.126 \n8th visit 1 0 -0.027 0.060 0.657 -0.143- 0.090 \n352\n353\n354 Mothers in both groups were similar in terms of; meal frequency (p=0.911), iron/folic acid \n355 supplementation at the 2nd -4th visits (β <= -0.035), maternal nutritional status by MUAC at the \n356 2nd – 4 th visits (β<= 0.038). Additionally there was no significant difference in maternal \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n357 instances of; headache at the 2 nd -4 th visits (β<=0.078), depression at the 2 nd -3 rd visit \n358 (β<=0.013) and diarrhoea at the 2nd -4th (β<=0.049) visits. \n359 Whereas mothers in the routine NACS group had a significantly higher diversity score at the \n360 2nd - 4th visits (p<0.001), the comprehensive group had higher weights at the 2nd - 4th (p<=0.003) \n361 visits. The difference in weights increased with number of visits right from the time of mothers’ \n362 enrolment. \n363 Compared to routine, infants born to mothers in the comprehensive group had a significantly \n364 higher;  birth weights at 10% level of significance (p=0.056, CI -0.005 – 0.387), weight-for- \n365 age at the 3 rd -6 th visits (p<0.001) with 20% reduction in underweight on average per visit.   \n366 Furthermore, their length-for-age was significantly higher at the 4 th -7th visits (p<0.001). The \n367 difference widened with the increasing number of visits. Similarly, the weight-for-length of the \n368 comprehensive NACS group was significantly much higher at the 3rd -5th visits (p<0.001). The \n369 difference remained constant throughout the subsequent visits. \n370 Unlike the routine group, infants in the comprehensive NACS group had significantly higher \n371 episodes of upper respiratory infections at the 5th -8th (p<0.001, β<=0.315). On the other hand, \n372 the routine NACS infants experienced a significantly higher episodes of; diarrhoea at the 5 th -\n373 8th visits (p<=0.061) and fever at the 1st (p=0.072, β=-0.054) and 4th visits (p<0.001, β=-0.409). \n374\n375\n376\n377\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n378 Discussion\n379 The study aimed to assess the effect of NACS integration on the maternal-infant nutrition \n380 practices, health and nutritional status. The findings provide insights into the potential benefits \n381 of nutrition integration on the health system on the wellbeing of the mothers and their infants. \n382 The key findings in light of existing evidence and their implication are discussed.\n383 The study found no significant difference in meal frequency among the mothers in both study \n384 groups, suggesting similar dietary habits. Compared to the comprehensive group, mothers in \n385 the routine NACS setting had a significantly higher diversity scores on all visits. This disparity \n386 may be attributed to the close proximity to the rural settings offering more natural and diverse \n387 food choices.  Maternal nutritional status by MUAC estimates exhibited no significant \n388 differences across the visits in the two study settings. In contrast to the routine group, mothers \n389 in the comprehensive displayed significantly higher weights at the 2nd- 4th visits. This implied \n390 that integration of comprehensive NACS had positive progressive impact on maternal weight \n391 gain from the time of enrolment. The findings suggest potential program implication and \n392 highlight the need to consider environmental context when implementing nutrition programs. \n393 Future nutrition interventions should therefore be tailored to the specific needs and context of \n394 the target population. Furthermore, the study re-enforces, existing body of evidence indicating \n395 that maternal focused interventions particularly those with a multi-sectoral nature contribute to \n396 improved maternal diet diversity, micronutrient intake and overall nutritional status [29–31].   \n397 Additionally, there were minimal difference in iron/folic acid supplementation between the two \n398 groups at the 2 nd - 4th visits implying consistent adherence to the Ministry of Health guidance \n399 on routine iron/folic acid supplementation among pregnant mothers in both settings. However, \n400 it is worth noting that the effect of iron/folic acid supplementation on haemoglobin levels in \n401 both settings could not be assessed in both settings due to lack of equipment and supplies. \n402 Studies by Michael Habtu et al [32], Sunita Taneja et al [7], Melesse Kuma et al [33]  revealed \n403 elevated haemoglobin levels among women in the intervention group, findings that our study \n404 was unable to replicate due to the constraints related to equipment and supplies.\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n405 The estimates showed no difference between the two settings for maternal episodes of \n406 headache, depression and diarrhoea across the various visits. This implies that these health \n407 concerns are common and not influenced by the study settings. These need to be addressed in \n408 both setting for the well being of mothers.\n409 Our investigation into the nutritional status of the infants revealed that integration of \n410 comprehensive NACS increased infant birth weights, reduced instances of underweight, \n411 stunted and wasted infants. This implies that nutrition integration had a potential benefit of on \n412 the foetal and infant growth and development. Our findings concur with; Veeena et al [34]  M \n413 Barker et al [8] , Von Salmuth et al [10], Olutayo et al [11], Micheal Habtu etal [35] on the \n414 effectiveness of a holistic approach to improving the nutritional status of children.  \n415 Routine NACS infants experienced significantly more episodes of diarrhea and fever at the \n416 various visits than the comprehensive NACS group. The findings concur with Gonzalenz-\n417 Fernandez et al [36] in their study in which implementation of the multisectoral approach \n418 lowered the risk of diarrhoea and respiratory infections. This implies that the health facilities \n419 in the routine NACS settings did not comprehensively address these health concerns hence the \n420 need for more interventions for better health and nutrition outcomes.\n421 One of the strengths of this study lies in its comparison of two separate groups; routine versus \n422 comprehensive and its close monitoring of the practices and outcomes of the study participants. \n423 This approach bolstered the study's findings, providing a clear and robust insight into the \n424 effectiveness of the integrated intervention package. Moreover the study places emphasis on \n425 favourable outcomes of comprehensive NACS highlighting the potential benefits of such \n426 comprehensive interventions, which findings are also consistent with the existing literature. On \n427 the other hand, the study lacked the ability to assess the impact of iron/folic acid \n428 supplementation on haemoglobin levels due to lack of equipment and supplies, which is a \n429 limitation in understanding the complete maternal health and nutrition outcomes. \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n431 Conclusions \n432 The findings add to the existing body of evidence supporting improved maternal-infant health \n433 and nutrition practices and status with integrated nutrition services. While meal frequency, \n434 iron/folic acid supplementation were similar in the both groups, integration of comprehensive \n435 NACS intervention improved; maternal weights, infant birth weights, infant growth in light of \n436 weight-for-age, length-for-age and weight-for-length. This emphasises the potential benefits of \n437 integrated nutrition interventions in promoting the overall being of the mothers and their \n438 infants.\n439 Recommendations\n440 Based on the above findings, the Ministry of Health should consider:  investing in acquiring \n441 the necessary equipment and supplies to assess the impact of iron/folic acid supplementation \n442 on haemoglobin levels for comprehensive evaluation of the women; scaling up integration of \n443 the comprehensive NACS in the health system as it has positive effect on the maternal-infant \n444 nutrition practices, health and nutrition outcomes; investing in digitization to ease monitoring \n445 and tracking trends in the health and nutrition status of the mother-infant pairs. \n446 Future research can focus on implementation and effectiveness of digitization in monitoring \n447 and tracking of the maternal-infant health and nutritional status in an integrated health system. \n448 Secondly, it will be important to investigate the experiences of the women and caregivers \n449 receiving these services. \n450\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n451 Supporting information\n452 S1 File Dataset for Tororo and Butaleja districts\n453 S1 Fig. Pathways on the effect of NACS integration into the health system on maternal and \n454 infant health, nutrition practices, and outcomes adapted from the Chronic Care Model \n455 S2 Fig.  Enrolment and data analysis flow chart\n456 Acknowledgements\n457 We extend our appreciation to the political and administrative authorities of Tororo and \n458 Butaleja districts for granting us the necessary permission to conduct this study. Our gratitude \n459 go to the health workers as well as the mothers and their infants from Tororo and Butaleja \n460 districts for the dedicated participation in advancing this research undertaking. Brian Wakoli \n461 is appreciated for the statistical support rendered during the analysis. \n462 Author contribution\n463 Conceptualization:  SN FEM GWM SNK\n464 Data Curation: SN FEM SNK\n465 Formal analysis: SN SNK FEM \n466 Funding acquisition: SN\n467 Investigation: SN\n468 Methodology: SN SNK FEM\n469 Project administration: SN\n470 Resources: SN\n471 Software: SN\n472 Supervision: SN FEM GWM SNK\n473 Validation: SN FEM GWM SNK\n474 Visualization: SN FEM \n475 Writing- Original draft: SN\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 21, 2023. ; https://doi.org/10.1101/2023.12.20.23300314doi: medRxiv preprint \n\n476 Writing – Review and editing: SN FEM GWM SNK\n477\n478 References\n479 1. Development Initiatives Poverty Research Ltd. Global Nutrition Report: Stronger \n480 commitments for greater action. Global Nutrition Report. Bristol. UK; 2022. \n481 Available: \n482 http://www.segeplan.gob.gt/2.0/index.php?option=com_content&view=article&id=47\n483 2&Itemid=472\n484 2. UBOS. Uganda Demographic and Health Survey 2016. Udhs. 2016. Available: \n485 www.DHSprogram.com\n486 3. Marshall NE, Abrams B, Barbour LA, Catalano P, Christian P, Friedman JE, et al. The \n487 importance of nutrition in pregnancy and lactation: lifelong consequences. 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